Lessons from the Literature

2020; Volume 21, No 7, July

Lessons from the Literature

Under My Microscope

Dr. Tania Pastrana. Used with permission.

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Use of Antibiotics among End-of-Life Hospitalized Patients with Advanced Directives: Status examination and association with infectious disease consultation and physician burnout

Fedorowsky R, Bachner YG, Borer A, Ciobotaro P, Kushnir T. Infect Control Hosp Epidemiol 2019; 40(11): 1222-1228. DOI: 10.1017/ice.2019.203

In the everyday praxis of palliative care we face decisions about pharmacological therapy, balancing its pros and cons. Whether or not to use antibiotics is one of these decisions.

A high proportion of patients in their final weeks of life are treated with antibiotics, without an effective or desired response. Moreover, overuse contributes to the increase of multidrug-resistant organisms, along with their medical, social, and economic consequences.

In a cross-sectional study conducted in 27 hospital wards in Israel, the authors assess antibiotic use by physicians in end-of-life (EOL) patients with advance directives, and investigate the association between infectious disease consultations, physician burnout, and antibiotic days of therapy in those patients.

The study comprised 213 physicians and 932 of their hospitalized patients in the last two weeks of life. The authors found that “74% received antibiotics until the last day of life, 29.9% had bacterial resistance cultures, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues.” The authors conclude that, “Antibiotics are overused in EOL patients with advanced directives.”

This paper illustrates the need to include infectious disease physicians when discussing end-of-life care, to improve care of the dying — but also for better care of the healthy. This collaboration could help control the growth of multidrug-resistant organisms.

Background: Overuse of antibiotics in end-of-life patients with advanced directives increases bacterial resistance and causes morbidity and mortality. Consultations with infectious disease (ID) physicians and burnout, which can affect antibiotic days of therapy (DOT) prescribed by physicians, have not been examined so far.

Objectives:To assess antibiotic use by physicians in end-of-life (EOL) patients with advanced directives and to investigate the association between ID consultations, physician burnout, and antibiotic DOT in those patients.

Design: A descriptive correlational study. Setting: Acute-care and post-acute-care hospitals. Participants: The study included 213 physicians and 932 their hospitalized patients in the last 2 weeks of life.

Methods: We distributed questionnaires and analyzed the data collected regarding ID consultation, EOL antibiotics prescription with and without an advanced directive, and physician burnout to 278 physicians, and 213 were completed (response rate 76%).

Results: Of the 932 deaths, 435 of 664 (>50%) were EOL patients with advanced directives. Of these patients, 74% received antibiotics, 29.9% had bacterial resistance cultures, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues and had significantly fewer consultations with ID physicians in EOL patients with advanced directives (mean rate, 0.27) than those without advanced directives (mean rate, 0.47). ID physicians reported significantly higher emotional exhaustion levels (mean rate, 29) than other medical specialties (mean rate, 19.2). Antibiotic DOT was significantly higher when patients had ID consultations (mean rate, 21.6) than in patients who did not (mean rate, 16.2). In post-acute-care hospitals and/or geriatric wards, antibiotic DOT was significantly higher than in other types of hospitals and/or wards. Depersonalization level was negatively related to antibiotic DOT (P < .05).

Conclusions: Antibiotics are overused in EOL patients with advanced directives. ID physician burnout and impact of ID consultation should be further assessed.

P.S. This month I also came across a thematic issue on primary palliative care (PPC) published in May by the journal Medical Clinics of North America [2020; 104 (3): 359-572]. Issue editor Dr. Eric Widera defines PPC as the “type of palliative care provided by clinicians who are not palliative care specialists.” The issue includes management of frequent symptoms in palliative care (such as pain, respiratory symptoms, gastrointestinal symptoms, and delirium) but also prognostication, management of urgent medical conditions, care conversations, and management of grief in order to improve their own abilities to care for those living with serious illness. It is surely an excellent strategy to disseminate basic concepts of palliative care in the health care community. Thank you and congratulations!

Do you have any questions regarding Under My Microscope?

Contact Tania Pastrana

Media Watch: Telehealth

Telehealth was gaining increasing attention before the pandemic, and has since gained even more. The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.

Webside Manner during the COVID-19 Pandemic: Maintaining human connection during virtual visits

Journal of Palliative Medicine | Online – 11 June 2020 – From a multisite study exploring the effectiveness of virtual palliative care, the authors identified key elements of webside manner when conducting serious illness conversations by virtual visit, as detailed in the table below. DOI: 10.1089/jpm.2020.0298.

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Table 1. Key Elements and Components of Webside Manner Skills

Key element


Proper set up

Select a quiet environment with minimal potential for disruptions.
Use a professional backdrop.
Test platform before first virtual visit.
Body position:
  • neutral relaxed posture
  • head and one-third of upper torso should be visible
Maintain eye contact.
Position camera at eye level.
Situate patient's onscreen image adjacent to the camera.

Acquainting the participant

Wave hello at the start of the visit.
Name the dilemma with the participant.
Acknowledge the new or awkward format.
Acknowledge that unexpected disruptions and ambient noise may occur.
Check in: “How can I make this experience better?

Maintaining conversation rhythm

Avoid prolonged silence; thoughtful brief pauses are favored.
Minimize overtalking.
Avoid saying “mm-hmm.” Gently nod instead.

Responding to emotion (e.g., sadness)

Focus on verbal responses.
  • “I wish…”
  • “Take your time. I am here.”
Consider nonverbal responses.
  • Lean in slightly to convey intentional listening.
  • Nod gently.
  • Place hand over heart to convey empathy.

Other considerations

Use phone when there are:
  • persistent technical difficulties.
  • participants who either do not have access to the requisite technology or find the virtual visit platform too technically challenging to navigate.
  • patients who are too ill to participate.
  • non-English speaking patients who require interpreters. Consider using a virtual visit platform that possesses interpreter services, or use the video platform to view the patient and use a separate interpreter phone service for audio.

Closing the visit

Summarize the visit.
Verify participant understanding.
Provide opportunity for the participant to voice thoughts, questions, or concerns.
Outline next steps based on goals-of-care conversation.

Reprint of “Table 1. Key Elements and Components of Webside Manner Skills” is courtesy of the Journal of Palliative Medicine and copyright holder Mary Ann Liebert Inc.; New Rochelle, NY.

Feasibility and Acceptability of Inpatient Palliative Care E-family Meetings during COVID-19 Pandemic

Journal of Pain & Symptom Management | Online – 4 June 2020 –During the COVID-19 pandemic ... the authors demonstrated the efficient deployment of telemedicine for e-family meetings that was both feasible and effective for decision-making for patients who were near end of life and their families. Family meetings likely happened sooner and with far more participants than would have been possible without the use of the technology. While providers expressed limitations in the use of technology ... they reported key benefits including observation of prayer rituals and promoting understanding to the family of the patient’s condition. DOI: 10.1016/j.jpainsymman.2020.06.001

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Can Video Consultations Replace Face-to-Face Interviews? Palliative medicine and the COVID-19 pandemic: Rapid review

BMJ Supportive & Palliative Care | Online – 26 May 2020 – The global evidence appears to support video consultations as an effective, accessible, acceptable and cost-effective method of service delivery. Organisations must ensure software is simple, effective, reliable and safe, with the highest level of security for confidentiality... Importantly, patients and relatives report video consultations to be highly acceptable and often wish it had been offered sooner. DOI: 10.1136/bmjspcare-2020-002326

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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